General Session: Thoraco-Lumbar Degenerative

Presented by: H-J Cho - View Audio/Video Presentation (Members Only)

Author(s):

J.-W. Hur(1), K.-S. Ryu(1), J.-S. Kim(1), J.-H. Seong(1), H.-J. Cho(1)

(1) Seoul St. Mary's Hospital, The Catholic University of Korea, Neurosurgery, Seoul, Korea, Republic of

Abstract

MIS-DLIF (direct lateral lumbar interbody fusion) using tubular retractor has been used for the treatment of lumbar degenerative diseases. Although addition of intraoperative monitoring (IOM) of neural structures potentially decreased the perioperative neurological complications, blunt retroperitoneal and trans-psoas dissection poses a risk of injury to the lumbar plexus, especially at lower lumbar level.
As an alternative, MIS-OLIF (oblique lateral lumbar interbody fusion) uses a window between the prevertebral venous structures and psoas muscle, and gets an access to the target disc obliquely. Theoretically, MIS-OLIF preserves psoas muscle and lumbosacral plexus with reducing the complication of direct lateral approach, and the need for IOM related to trans-psoas approach is questionable.
The purpose of this study was to evaluate the safety of MIS-OLIF without IOM by comparing the incidence of perioperative complication in patients who underwent multi-level OLIF with or without IOM for the treatment of lumbar degenerative disease. From October 2013 to March 2016, 129 consecutive patients underwent multi-level OLIF for the treatment of L1-S1 level degenerative disease were identified and retrospectively reviewed.
The study group comprised 57 patients in IOM group (M:F=1:1.37, mean age=65.8 (range 35~83)) and 72 patients in non-IOM group (M:F=1:2.1, mean age=67.1 (range 40~85)). For clinical outcomes, self-reported measures including visual analogue scale (VAS) and Oswestry disability index (ODI) were used. A perioperative complication classification based on the relation to surgical procedure and effect duration was used. Perioperative complications until 3 month postoperatively were reviewed for the patients.
There was significant improvement of clinical outcomes in both groups without statistically significant difference.
Overall, there were 13 (22.8%) procedure-related complications in IOM group and 17 (23.6%) in non-IOM group. In IOM group, there were 7 (12.2%) cases of transient leg symptoms that resolved spontaneously within 3 month postoperatively, including: 1 case of hip flexor weakness; 2 leg numbness; 1 leg pain, 2 asymptomatic temperature differences between each lower extremity and 1 asymptomatic leg swelling. In non-IOM group, there were 11 (15.2%) cases of transient leg symptoms; 2 case of hip flexor weakness; 3 leg numbness; 1 leg pain, 3 cold sensation and 2 leg swelling. Of all procedure-related complications in IOM group, 4 (7.0%) were classified as persistent, and 3 (4.1%) in non-IOM group. There were 3 procedure-related persistent leg symptoms in both groups respectively but without statistical difference (5.2% vs 4.1%) The most common procedure-related complication in both group were transient leg hypesthesia & cold sensation (3.5% vs 4.1%, N/S). The overall incidence of approach-unrelated complication accounted for 7.0% in IOM group and 8.3% in non-IOM group respectively. There were 4 re-operation cases in IOM group (7%; 1 local hematoma, 1 postoperative infection, 1 screw malposition, 1 persistent leg pain) and 3 in non-IOM group (4.1%; 1 local hematoma, 1 postoperative infection, 1 ureter injury). In our report of multi-level lumbar diseases, the OLIF technique may be performed safely without the aid of IOM in terms of procedure-related perioperative neural complications by eliminating the risk of unwanted muscle and nerve manipulations.